Idaho Department of Finance

Industrial Revenue Bond Issuer Report Form

The undersigned,  hereby certified the following information  
Bonds Issued:  
Date of Issuance:  
Facilities constituting the project:  
Persons on behalf of whom the issuer issued the bonds:  
The amount of permanent employment reasonably expected to be created by the existence of the project:   

By affixing my name to this application I, ,  hereby certify, that I have executed this report on behalf of, and with the authority of the issuer. I and the issuer represent that the information and statements contained in the notice filed, are current, true and complete to the best of my knowledge, information and belief and that any documents submitted with the notice are true copies of the originals.

By affixing my name, date of birth, and mother's maiden name, and submitting this application electronically, I understand that I am as fully responsible for the contents herein as though I had signed and submitted this application manually.

Dated this:  
Date of Birth:  
Mother's Maiden Name:  
City State: Zip